RFI PWS NSA Complaint Processing 02.11.26.docx

Performance Work Statement (PWS) No Surprises Act (NSA) Provider Complaint Processing for EBSA

Background:

Enacted as part of the Consolidated Appropriations Act on December 27, 2020, the No Surprises Act (NSA) introduced significant protections for individuals against surprise medical bills. These protections cover emergency services, non-emergency services rendered by nonparticipating providers with respect to a visit to a participating health care facility, and air ambulance services provided by nonparticipating providers. A key element is the establishment of complaint processes related to potential violations of the NSA. Specifically, the NSA mandates that the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury create mechanisms for receiving complaints regarding violations of the NSA by group health plans and health insurance issuers offering group or individual health coverage, with a directive to respond to such complaints within 60 days.

Under the Employee Benefits Security Administration (EBSA) contract, the scope of work will include triaging and handling complaints from medical providers regarding alleged NSA violations. The contractor is tasked with efficiently implementing triage and handling processes, following standard operating procedures to ensure comprehensive documentation and resolution of complaints, and guaranteeing timely responses to complainants.

Objectives:

Activities undertaken as part of this support include, but are not limited to, receiving training to become adept with EBSA’s inquiry and complaint tracking system, the Agency’s standard operating procedures related to NSA complaints, and statutory provisions of the NSA. This training is required to efficiently prioritize complaints; ensure appropriate response actions; thoroughly document, review, and resolve NSA complaints; and respond to complaints within the timeframes dictated by EBSA’s standard operating procedures and the requirements of the NSA statute.

Scope:

The contractor will:

Complaint Reception and Management: Prioritize and resolve complaints for timely response and resolution within the EBSA customer service standards and the NSA's 60-day response mandate.

Task 1 Kickoff: Participate in a kickoff meeting to receive details of the project’s scope and requirements.

Task 2 Contract Training: Receive training on the health plans, NSA, Technical Assistance Inquiry System (TAIS) operations, agency standard operating procedures, and complaint handling requirements.

Task 3 Daily Complaint Review: Follow agency procedure to conduct assessments of new complaints received each day to (1) identify complaints that are not from medical providers, (2) flag complaints that are outside of DOL’s jurisdiction, (3) correct data errors that would impede accurate reporting on NSA complaints, and (4) designate the violation being alleged by the complainant. Expect to review approximately 100 new complaints each workday.

Task 4 Jurisdiction Notification: Inform the Office of Outreach, Education and Assistance (OEA) about complaints that are not from a medical provider or that are outside DOL jurisdiction, ensuring correct routing of those complaints.

Tasks 5 Complaint Management Process: The task involves processing health coverage complaints per SOP guidelines, including acquiring necessary information and documents from complainants; contacting health plans and health claims administrators to obtain details regarding the processing of the claims in question; with direction from OEA, advising health plans how to self-correct violations; documenting any such corrections; notifying the complainant of the results of the Agency’s review; and limiting disclosure of personally identifiable information and protected health information to the minimal extent needed to resolve the complaints. Communication with complainants and health plans uses pre-approved emails and phone follow-ups. Responses are conveyed to complainants for actionable feedback, maintaining contact with the Office of Outreach, Education, and Assistance (OEA) for unresolved cases. Adherence to OEA directives and customer service standards is crucial, with detailed records kept in the Agency's TAIS system.

Through these tasks, the contractor will reinforce NSA's protective measures, sustain accountability, and uphold public trust by ensuring a systematic and responsive approach to complaint management.

Task 6 Reporting: Provide a monthly report to the Office of Outreach, Education and Assistance (OEA) detailing the number of open complaints assigned to each worker in the prior month, the number of complaints closed by each worker during the prior month, and the number of complaints closed with a benefit recovery in the prior month.

Task 7 Surge Capacity (Optional): When authorized by the CO/COR, the Contractor shall provide additional trained personnel and extended operational coverage to address short-term increases in NSA complaint volume. The contractor will perform Task 2 through 6 as needed.

Period of Performance:

The period of performance shall be for a one 12-month base period and four 12-months option periods.

Specific Tasks

5.1 Services:

The contractor shall:

Task 1: Conduct Kick-Off Meeting

· To be conducted virtually or on-site with essential Government and Contractor staff.

· Discuss agency requirements.

Task 2: Contractor Training

· EBSA will provide training documents for the Contractor to review. The Contractor will not disclose or share training documents with anyone who is not a party to this contract.

· The Contractor shall participate in training exercises to ensure contract staff have the appropriate knowledge on ERISA, the NSA, use of TAIS, OEA standard operating procedures, and any other information or knowledge needed to perform the contract, as determined by EBSA.

· The Contractor shall raise any clarifying questions necessary to ensure adequate understanding of task requirements and must make all proposed personnel available for this training.

· EBSA reserves the right to require Contractor personnel to attend additional training at any time during the contract term.

Task 3: Daily Complaint Review

Following agency procedures to conduct assessments of new complaints assigned each day, the contractor will:

· Identify complaints that are not from medical providers,

· Flag complaints that are outside of DOL’s jurisdiction,

· Notify OEA when the Agency receives complaints about Certified Independent Dispute Resolution Entities (IDREs),

· With guidance from OEA, correct data errors that would impede accurate reporting on NSA complaints, and

· Designate the violation being alleged by the complainant.

· Expect to review approximately 100 new complaints each workday.

· Transfer complaints to the correct EBSA region where there is an open field investigation on the insurer, with approval by OEA.

Task 4: Jurisdiction Notification

Contractor will inform OEA about these categories of complaints within 2 business days of assignment:

· Complaints about IDREs, including complaints that the IDRE’s determination is invalid for any reason,

· Complaints about health plans sponsored by government entities or religious organizations,

· Complaints related to Medicaid or Medicare coverage,

· Complaints from someone other than a medical provider or a medical provider’s billing representative,

· Complaints about fixed indemnity insurance policies, and

· Complaints related to individual (non-group) insurance coverage.

Task 5: Complaint Management Process

· Obtain missing information (e.g., about the type of health coverage, the name of the health plan sponsor, or the specific claim item or service at issue) from complainants as directed by agency Standard Operating Procedures (SOPs).

· Contact health plans using the telephone or pre-approved email templates to solicit responses to complaints.

· Use the telephone to follow up on email requests and responses.

· Convey health plan responses to complainants and determine, in consultation with OEA, follow-up actions based on complainants’ feedback.

· Maintain ongoing communication with the OEA regarding unresolved complaints, seeking further guidance for complex cases.

· Follow OEA directives for handling complaints.

· Comply with OEA customer service standards.

· Track all information pertaining to complaints, detail all steps taken to resolve complaints, manage all correspondence and responses, and maintain all complaint documents and correspondence within the Agency’s TAIS system.

· Handle existing backlog of complaints previously assigned to EBSA benefits advisors.

· When applicable, submit benefit recoveries for OEA to review, following the procedures outlined in OEA Standard Operating Procedure 3.

Task 6: Reporting

· Provide a monthly report to OEA.

· The report will describe for the prior month: the number of open complaints assigned to each worker in the prior month, the number of complaints closed by each worker during the prior month, and the number of complaints closed with a benefit recovery in the prior month.

Task 7 Surge Capacity (Optional): When authorized by the CO/COR, the Contractor shall provide additional trained personnel and extended operational coverage to address short-term increases in NSA complaint volume. The contractor will perform Task 2 through 6 as needed.

TECHNICAL EXHIBIT 2

Deliverables Schedule

Program Office POC

Program Office POC

Program Office POC

Daily

Periodic feedback from OEA

Program Office POC

Daily

Periodic feedback from OEA

Program Office POC